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Tin certificate 2026

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The document is a Certification Statement for Provider Billing Medicaid, which outlines the responsibilities and affirmations of providers submitting claims to New York State's Medicaid program. It certifies that the provider is qualified, compliant with laws and regulations, and that all claims submitted are accurate and necessary. The statement must be signed, dated, and notarized, remaining in effect until replaced by a new certification. Instructions for completing the form are also provided.

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Click ‘Get Form’ to open the tin certificate in the editor.
In Field 1, enter the provider name as it appears on official documents.
For Field 2, input your 10-digit National Provider Identifier (NPI). If you are exempt from NPI, proceed to Field 3.
If applicable, enter your Tax ID in Field 3. Ensure accuracy to avoid processing issues.
In Field 4, provide your signature. This must be an original signature for validation.
Enter the date of signing in Field 5 and print your name and title in Field 6.
Fill in your telephone number in Field 7 and email address if available in Field 8.
Field 9 requires notarization. Ensure a notary public completes this section with their seal.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (96 Votes)

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